零缺血指数对不阻断肾动脉保留肾单位手术风险和结果的评估作用

The efficiency of zero ischemia index in predicting complexity and outcomes of off-clamp nephronsparing surgery

目的探讨零缺血指数（ZII）对不阻断肾动脉的保留肾单位手术（NSS）的风险和结果的评估作用。 方法前瞻性收集2016年6月至2017年6月收治的肾肿瘤患者的临床资料。纳入标准：①年龄≥18岁；②有完整影像学资料；③T1期肾肿瘤；④中山评分〈8分。排除标准：①年龄〈18岁；②T2期肾肿瘤；③中山评分≥8分；④随访数据不完整。患者均行不阻断肾动脉的NSS。将肿瘤肾内直径和肾内纵径乘积作为ZII，以ZII＝6为界将患者分为低危组（≤6）和高危组（〉6），比较两组患者的手术时间、术中出血量、术后住院时间、术后引流量和并发症发生情况。 结果本研究共纳入45例患者，男35例，女10例。年龄23～76岁，平均42岁。肿瘤直径0.8～4.2 cm，平均2.4 cm。33例行改良小切口开放式不阻断肾动脉NSS，12例行腹腔镜不阻断肾动脉NSS。44例顺利完成NSS，1例因术中出血量大阻断肾动脉。手术时间（95.0±17.5）min，范围50～150 min。术中出血量（152.4±134.2）ml，范围20～600 ml。术后引流量（97.3±59.7）ml，范围50～300 ml。术后住院时间（6.1±1.3）d，范围5～8 d。术后均未发生严重外科并发症。低危组37例，高危组8例。低危组手术时间明显短于高危组[（89.9±13.4）min与（118.8±14.6）min，P〈0.01]；术中出血量明显少于高危组[（104.3±61.4）ml与（375.0±158.1ml），P〈0.01]；引流量明显少于高危组[（83.5±40.4）ml与（161.2±91.3）ml，P〈0.01]。两组术后住院时间比较差异无统计学意义（P〉0.01）。病理诊断为肾透明细胞癌35例，肾嫌色细胞癌2例，乳头状肾细胞癌1例，肾血管平滑肌脂肪瘤7例。其中38例恶性肾肿瘤患者随访1～14个月，未见复发和转移。 结论ZII可对不阻断肾动脉NSS术中风险尤其是出血风险进行预先估计。ZII＝6可作为是否进行不阻断肾动脉NSS的分界值。

ObjectiveTo evaluate the efficacy of zero ischemia index （ZII） in predicting the complexity and perioperative outcomes of off-clamp nephron-sparing surgery （NSS）. MethodsThe patients between June 2016 and June 2017 in our institution who underwent off-clamp NSS were prospectively evaluated. ZII was defined as the product of the tumor diameter and depth within renal parenchyma. The ZII〉6 defined as higher risk while ZII≤6 defined as low risk. The operating time, estimated blood loss, hospital stay, drainage, and complication rate were analyzed. ResultsThere were 35 males and 10 females with average age of 42 y（range 23-76y）. Mean tumor size was 2.4 cm （range 0.8-4.2 cm）. Mini-flank approach open NSS was performed in 33 cases and laparoscopic NSS was performed in 12 cases. Off-clamp NSS was successfully performed in 44 patients except for renal artery occlusion in 1 case. Mean operative time was （95.0±17.5） min （range 50-150 min）; The average estimated blood loss was （152.4±134.2） ml （range 20-600 ml）; Mean postoperative drainage was （97.3±59.7）ml （range 50-300 ml）; Mean postoperative hospital stay was （6.1±1.3） d （range 5-8 d）. Not severe post operative complication was observed. There were 37 patients in low risk group and 8 patients in high risk group. Operating time was significantly longer in high risk group [（118.8±14.6 min） vs. （89.9±13.4） min, P〈0.01]. EBL [（375.0±158.1） ml vs. （104.3±61.4） ml, P〈0.01] and drainage [（161.2±91.3）ml vs. （83.5±40.4）ml, P〈0.01] were also significantly higher in high risk group. But there was no significant difference in hospital stay between two groups. The postoperative pathology indicated that 35 cases of clear cell carcinomas, 2 cases of chromophobe renal cell carcinomas, one case of papillary carcinoma and seven cases of angiomyolipomas. ConclusionsThe ZII is a novel and effective measurable criterion which can help predict the risk of perioperative outcomes of off-clamp NSS. ZII=6 is established as a preliminary threshold for patient selection of off-clamp NSS.